Provider Demographics
NPI:1063854131
Name:RADZISZEWSKI, MARYLA (LMT)
Entity Type:Individual
Prefix:
First Name:MARYLA
Middle Name:
Last Name:RADZISZEWSKI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:EAST HADDAM
Mailing Address - State:CT
Mailing Address - Zip Code:06423-1251
Mailing Address - Country:US
Mailing Address - Phone:860-796-1071
Mailing Address - Fax:
Practice Address - Street 1:62 CREAMERY RD
Practice Address - Street 2:
Practice Address - City:EAST HADDAM
Practice Address - State:CT
Practice Address - Zip Code:06423
Practice Address - Country:US
Practice Address - Phone:860-796-1071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006441225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist